Croup

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full CAHS Emergency Department disclaimer.

Aim

To guide PCH Emergency Department staff with the assessment and management of croup.

Definition

Croup (laryngotracheobronchitis) is an upper respiratory illness characterised by a hoarse voice, barking cough, and stridor. The clinical symptoms are a result of inflammation and narrowing of the upper airway (larynx, trachea and bronchi).

Background 

• Croup is most commonly caused by the Parainfluenza virus, but a variety of respiratory viruses (including COVID-19^2,3) may be responsible
• Symptoms are usually more prominent at night
• Most cases are mild (and do not require admission)
• Severe cases can be life-threatening due to potential airway compromise

Assessment^1,4

• Do not upset the child – this will exacerbate the symptoms
• The severity of the stridor is not an indication of the severity of croup

History

• Ask about the onset and duration of symptoms:
  • Coryza
  • Cough
  • Stridor
  • Increased work of breathing.
• Possibility of inhaled foreign body or anaphylaxis
• Past history – e.g. previous episodes of croup, underlying upper airway, abnormality, underlying neuromuscular conditions.

Examination

• It is important not to exacerbate the symptoms by upsetting the child – keep your assessment short and as non-invasive as possible. Keep the child in their most comfortable position (e.g. in their parent’s arms)
• Observations: heart rate, respiratory rate, temperature, oxygen saturations and blood pressure
• Behaviour:
  • Alert and interested in surroundings or
  • Altered conscious state e.g. irritable, lethargic
• Respiratory assessment:
  • Cyanosis (this is a very late sign),
  • Barking cough,
  • Stridor (when upset or at rest),
  • Air entry on auscultation, there may also be wheeze.
• Work of breathing:
  • Degree (mild, moderate or severe)
  • Recession (sternal, intercostal, subcostal, tracheal tug).
• Monitor for signs of impending respiratory exhaustion.

Clinical severity 

Mild symptoms	Moderate symptoms	Severe symptoms
Barking cough No stridor at rest No sternal recession or tracheal tug Normal behaviour	Barking cough Audible stridor at rest Mild sternal regression +/- tracheal tug May be irritable at times	Persistent stridor at rest Pallor and mottling Severe sternal recession +/- tracheal tug Drooling Irritable or lethargic

Investigations

• Not required in clinical diagnosis of croup
• Routine viral testing is not required and does not alter management
• Chest X-ray is not indicated (except for those in extremis, i.e. those considered for Paediatric Critical Care (PCC) admission). 

Differential diagnoses⁴

• Underlying congenital abnormality eg: laryngomalacia, tracheomalacia
• Inhaled foreign body
• Anaphylaxis
• Epiglottitis
• Bacterial tracheitis.

Management¹

• All children who present to ED with croup should receive corticosteroids^5,6,7
• Additional treatments depend on the severity and may include nebulised adrenaline (epinephrine)⁸
• See Appendix 1: Croup Management Flowchart below

Croup Management Flowchart

Click on the image to download a high resolution PDF

Resuscitation^9,10

Life threatening croup:

• Transfer the child to the Resuscitation Room, activate the resuscitation team
• Immediately give nebulised adrenaline (epinephrine) 1:1000 (1 mg/mL) ampoule: 0.5 mg/kg/dose (0.5 mL/kg/dose) up to a maximum 5 mg (5 mL).
  • Refer to adrenaline (epinephrine) (internal WA Health only) in the table below for administration instructions
• Administer high flow oxygen (15L/minute via a non-rebreather mask)
• Call PCC, anaesthetics and ENT for assistance
• Prepare for intubation (ideally done in the operating theatre by anaesthetic and ENT teams). 

Initial management

Severe croup is treated as above with high flow oxygen and nebulised adrenaline (epinephrine).

• Adrenaline can be repeated 15 minutely as required. 
• All children requiring nebulised adrenaline (epinephrine) should be observed for at least 3 hours.⁸

All severe and life threatening croup should be discussed with a Senior Doctor and the child admitted under the General Paediatric Team.

Moderate croup will need observation (e.g. ED short stay unit (ESSU)) until there is no stridor at rest. 

Mild croup will not need observation and can be discharged home, after administration of oral corticosteroid. 

Medications

Corticosteroids^5,6,12,13

• Corticosteroids start working by 30 minutes⁷ and reduce time in hospital, transfers to PCC, the chances of intubation for inpatients, and also reduce the likelihood of relapse after discharge home.
• Corticosteroid therapy is extremely successful in treating stridor, but does not resolve the underlying viral symptoms.
• A single dose of corticosteroid is usually all that is required in mild to moderate croup.

Medication	Dose	Route	Treatment
Dexamethasone15	0.15 mg/kg	PO	All croup presentations should be treated with oral dexamethasone.
Prednisolone13	1 mg/kg	PO	If oral dexamethasone is not available.
Dexamethasone15	0.15 mg/kg	IM	Rarely required. Can give if oral corticosteroids are not tolerated (e.g. vomited).
Dexamethasone15	0.6 mg/kg (Max. dose 16mg10)	IV	For severe cases of croup (PCC candidates).

Adrenaline (Epinephrine)⁸

• The effect of nebulised adrenaline (epinephrine) is short lived and is thought not to change the natural history of croup. It may be repeated after 15 minutes if necessary. Children receiving adrenaline (epinephrine) need to be observed for a minimum of 3 hours afterwards.

Preparation	Dose	Maximum dose	Dilution volume	Route/delivery
Adrenaline epinephrine  (internal WA Health only) ampoule 1:1000 (1 mg/mL)	0.5 mg/kg  equivalent to 0.5 mL/kg	5 mg equivalent to 5 mL	Doses of 5 mL can be given undiluted. Doses <5 mL: dilute with sodium chloride 0.9% up to a final volume of 5 mL.	To be given with oxygen at 8 litres per minute via nebuliser. (Oxygen delivery at less than 8 litres per minute will not drive the nebuliser adequately)

Admission criteria

• As a 'rule of thumb' children without stridor do not need to be admitted
  • This decision would be influenced by the distance parents live from the hospital, the reported severity of symptoms at home and past history of severe croup.

Infection control

• Children presenting to hospital with croup should be managed with droplet precautions.

Discharge criteria

The child must meet all of the following criteria:

• Clinically improved
• Steroids received
• No stridor at rest
• No other clinical or social concerns.

Nursing

• Minimal nursing intervention is encouraged to avoid distressing the child and increasing respiratory distress.
• Patients should remain in a position of comfort.
• Children with croup require close observation.
• Complete and record a full set of observations on the Observation and Response Tool and record additional information on the Clinical Comments chart.
• Record baseline observations: heart rate, respiratory rate, oxygen saturations and temperature on the Observation and Response Tool and document additional observations on the Clinical Comments chart.
• The presence or absence of the following clinical features should be assessed and documented:
  
  • stridor
  • barking cough
  • degree and type of recession (i.e. mild, moderate, severe, intercostal, subcostal, tracheal tug)
  • air entry
  • cyanosis
  • conscious state (normal or altered).
• Observations should be recorded at least hourly whilst in the emergency department.
  
  • Any significant changes should be reported immediately to the medical team.
• Oxygen saturations and continuous cardiac monitoring is recommended if adrenaline (epinephrine) is given.
  
  • Before applying consider whether the risk of distress negates the accuracy of monitoring.

References 

1. Wright, M., Bush, A., 2016. Assessment and management of viral croup in children: Viral croup. Prescriber 27, 32–37.
2. SARS-CoV-2 and croup, not a rare coincidence. Peterson K, Patel J, Collier C, Chan SB Am J Emerg Med. 2022;57:175. Epub 2021 Dec 21
3. Brewster RC, Parsons C, Laird-Gion J, et al. COVID-19-Associated Croup in Children. Pediatrics 2022; 149
4. Wood CR. UpToDate: Croup:Clinical features, evaluation and diagnosis. 2023. UpToDate
5. Geelhoed GC, Turner J, MacDonald WB. Efficacy of a small single dose of oral dexamethasone for outpatient croup: a double blind placebo controlled clinical trial. Br Med J 1996;313:140‐2
6. Geelhoed GC. Sixteen years of croup in a Western Australian teaching hospital: effects of routine steroid treatment. Ann Emerg Med 1996;28:621‐6
7. Dobrovoljac M, Geelhoed GC How fast does oral dexamethasone work in mild to moderately severe croup? A randomised double blinded trial. Emergency Medicine Australasia. February 2012; 24(1);79‐85, 2012
8. Bjornson, C., Russell, K., Vandermeer, B., Klassen, T.P., Johnson, D.W., 2013. Nebulized epinephrine for croup in children. Cochrane Database Syst. Rev. CD006619.
9. Samuals M, Wieteska S (Ed) Advanced Paediatric Life Support Group. Advanced Paediatric Life Support The Practical Approach. 6th Edition. Australian Edition. Wiley‐Blackwell, Chichester. 2016. ISBN 9781119241225
10. Wood CR. UpToDate: Management of Croup. 2023 UpToDate
11. Chub-Uppakarn, S., Sangsupawanich, P., 2007. A randomized comparison of dexamethasone 0.15 mg/kg versus 0.6 mg/kg for the treatment of moderate to severe croup. Int. J. Pediatr. Otorhinolaryngol. 71, 473–477.
12. Parker, C., Cooper, M. 2019. Prednisolone Versus Dexamethasone for Croup: A Randomized Controlled Trial. Pediatrics 144(3)
13. AMH Children’s Dosing Companion. A-Z Drug Finder, Prednisolone/Prednisone, Updated July 2021 (As viewed 30 September 2021) Prednisolone/prednisone - AMH Children's Dosing Companion (health.wa.gov.au)
14. AMH Children’s Dosing Companion. A-Z Drug Finder, Dexamethasone, Updated July 2021 (As viewed 30 September 2021) Dexamethasone - AMH Children's Dosing Companion (health.wa.gov.au)
15. Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol 1995;20:362‐8.

Endorsed by:	CAHS DTC	Date:	June 2023
		Review date:	June 2026

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